Management of Belching, Hiccups, and Aerophagia

Albert J. Bredenoord


Clin Gastroenterol Hepatol. 2013;11(1) 

In This Article


Similar to belching, hiccups are common and usually occur occasionally. Only when multiple or prolonged episodes with hiccups occur is it considered pathologic. The medical term of hiccups is singultus. It is unknown whether hiccups serve a physiologic role.

Hiccups are involuntary spastic contractions of the respiratory muscles. Often only left unilateral diaphragmatic contractions are involved but sometimes both sides of the muscular diaphragm and the intercostal muscles are involved.

Hiccups can be classified based on duration. Hiccups lasting more than 48 hours are categorized as "persistent" and hiccups lasting more than 1 month are referred to as "intractable."[42]

Hiccups are mediated through a reflex arch consisting of afferent vagal, phrenic, and sympathetic nerves; central processing in the brainstem; and efferent signaling to the muscles of diaphragm and intercostal muscles.[43] A lesion or stimulus that triggers one of the branches of this reflex arch can cause hiccups. For many listed causes of hiccups, the evidence is not overwhelming but some causes have been well documented, including a response to treatment of the underlying cause. For example, hiccups induced by a stroke disappeared after treatment with anticoagulant drugs, likewise it was described that hiccups disappeared after treatment of meningitis.[44–46] Not only can damage to the relevant nerves cause hiccups, but a supranormal stimulus also can induce hiccups. For example, distention of the esophagus or stomach with air or food, drinking hot fluids, and also gastroesophageal reflux and angina pectoris can cause hiccups.[47–51] It has been described that hiccups were initiated by supragastric belching.[52] It also has been described that patients develop hiccups after placement of a central venous line, placement of an esophageal stent in a patient with esophageal cancer, bronchoscopy, and during electrical pacing of the left atrium.[53–55] Hiccups also can be associated with uremia.[56] A list of described causes of hiccups can be found in Table 2.[57] It is likely that the listed systemic factors induce hiccups by triggering the central nervous system as well (Table 2 and Table 3).

Management of Hiccups

Most episodes with hiccups are transient and self-limiting and may never need evaluation or treatment. When hiccups start during invasive procedures such as bronchoscopy or during infusion of anesthetics or chemotherapy, the underlying cause is identified easily. However, sometimes the trigger cannot be identified immediately and a search for an underlying cause is warranted. The clinical evaluation of a patient with persistent or intractable hiccups is found in Table 3. Of these investigations, magnetic resonance image of the brainstem and esophageal manometry and 24-hour impedance–pH monitoring are not always indicated and can be performed in case there are additional symptoms or signs that suggest a central or esophageal cause. When this yields a treatable cause, the problem can be solved but sometimes a causative factor is never found or, sometimes, in particular in patients in whom cancer is the cause of hiccups, a purely symptomatic treatment is indicated. Physical maneuvers as described in Table 4 usually already have been tried and are not useful anymore in this stage[58] (Table 4).

There are various reports on the medical treatment of hiccups, but few of the available drugs have been tested in a controlled study. Choice of treatment thus is based mainly on anecdotic reports and expert opinion, although the effect of some drugs is very likely, other reports describe an unlikely relation between drug and effect or an unlikely effect in itself.

The most well-known drug for the treatment of intractable hiccups is chlorpromazine.[59] In the United States, this is the only agent approved for this indication, meaning that all other drugs are used off-label. Chlorpromazine is started in a low dose (25 mg 3–4 times/d) and the dose can be increased when side effects allow it. Common side effects are drowsiness and sleepiness and, more rarely but also more serious, sometimes tardive dyskinesia can be encountered. GABA agonists baclofen and gabapentin are both described as being effective in 3 of 4 patients with intractable hiccups, but side effects such as dizziness and sleepiness may limit chronic use of these drugs.[60,61] Baclofen is started in a dose of 5 mg 4 times/d and this can be increased slowly. Case reports also have suggested the use of other drugs such as carvedilol, metoclopramide, nefopam, amantadine, olanzapine, and midazolam, although the latter also can induce hiccups when used as a sedative.[62–64] Marijuana also has been described as being effective in the treatment of intractable hiccups.[65]

In case hiccups are intractable and no alleviation is obtained with medical therapy, one can resort to ultrasound-guided nerve blockade or surgical section of the phrenic nerve. A case series described a successful implantation of an implantable breathing pacemaker that stimulates the phrenic nerve.[66] There are also reports on the use of hypnosis and acupuncture.[67–69]